Claims workbench/CLM-2026-022373
Professional claim · CMS-1500 · EDI 837P

CLM-2026-022373

Northgate Clinical Laboratories, Clinical Laboratory. Service 2025-12-04 at independent laboratory (POS 81). Received 2026-01-03.

PendedIdentity on hold: CASE-000250
Billed
$76.00
2 lines
Allowed
$47.12
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Robert Mason
Member ID
none on golden record
Date of birth
1978-01-24
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-431076
Relationship
Spouse, Orlando, FL

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Northgate Clinical Laboratories
Clinical Laboratory · taxonomy 291U00000X
NPI
7617256269
Network
In network
Rendering NPI
7617256269
Location
Denver, CO · TIN 27-8863034
Authorisation / referral
none / REF760902

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$42.00$26.04——PendedIDQ
287086Urine culture—11$34.00$21.08——PendedIDQ
Totals$76.00$47.12——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
Patient account
PA-604828
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-000250; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 30 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Northgate Clinical Laboratories (7617256269).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Northgate Clinical Laboratories2025-12-04 13:34

    Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-000250; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity